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Definitions

• the disclosure relates generally to methods for reducing adverse effects associated with the treatment of diseases and disorders. More particularly, the disclosure relates to methods for reducing abnormal liver function associated with 5-methyl-1-phenyl-2-(1H)-pyridone ("pirfenidone”) therapy.
• pirfenidone 5-methyl-1-phenyl-2-(1H)-pyridone
• U.S. Pat. Nos. 3,974,281 , 4,042,699 , and 4,052,509 generally relate to pirfenidone administration.
• U.S. Pat. Nos. 5,310,562 , 5,518,729 , and 5,716,632 all to Margolin and incorporated by reference herein, relate to pirfenidone administration.
• Pulmonary fibrosis can be caused by a number of different conditions, including sarcoidosis, hypersensitivity pneumonitis, collagen vascular disease, and inhalant exposure.
• Idiopathic pulmonary fibrosis IPF is a distinct entity, characterized by breathing difficulty, radiographic abnormalities, and progressive loss of lung function. It is invariably progressive, and carries a grave prognosis with a median life expectancy of 2-3 years.
• Pirfenidone has been administered to IPF patients.
• Raghu et al. (“Treatment of idiopathic pulmonary fibrosis with a new antifibrotic agent, pirfenidone: results of a prospective, open-label phase II study.” Am J Respir Crit Care Med 159:1061-1069, 1999 ) reported administration of pirfenidone. No adverse events in hematology or blood chemistry were noted.
• Abnormal liver function may manifest as abnormalities in levels of biomarkers of liver function, including alanine transaminase, aspartate transaminase, bilirubin, and/or alkaline phosphatase, and may be an indicator of drug-induced liver injury. See FDA Draft Guidance for Industry. Drug-Induced Liver Injury: Premarketing Clinical Evaluation, October 2007 .
• One aspect of the invention provides methods for administering a therapeutically effective dose of pirfenidone to a patient that has exhibited abnormal biomarkers of liver function after pirfenidone administration for the treatment of fibrosis, e.g. idiopathic pulmonary fibrosis (IPF).
• a patient is identified who exhibits a significantly abnormal level of one, two, three or more biomarkers of liver function, e.g. the level of a Grade 2 abnormality, after administration of an original full target dose of pirfenidone, e.g. about 2400 mg/day or 2403 mg/day.
• the dose of pirfenidone is reduced or discontinued until levels of the abnormal biomarkers approach or are within normal range, after which patients are administered increasing doses of pirfenidone, up to the original full target dose.
• the dose of pirfenidone is not reduced at all, but liver biomarkers continue to be monitored.
• patients are administered pirfenidone at a permanently reduced dose of 1602 mg/day.
• original full target dose means the therapeutically effective dose approved by the U.S. Food and Drug Administration or a similar agency in a foreign country, optionally other than Japan.
• the original full target dose is about 2400 mg/day or 2403 mg/day pirfenidone, or about 34 mg/kg/day (e.g. 33-35 mg/kg/day), or from 2200 to 2600 mg/day pirfenidone, or from 31 mg/kg/day to 37 mg/kg/day.
• the total daily dose is administered one, two or three times per day.
• the invention provides methods of administering pirfenidone to a patient at doses of 2400 mg/day or 2403 mg/day after identifying that the patient has exhibited a liver function Grade 2 abnormality after pirfenidone administration.
• the methods involve continuing the full target dose, e.g. of 2400 mg/day or 2403 mg/day, without temporarily discontinuing or reducing the dose.
• the patient's biomarkers of liver function may continue to be monitored.
• the method involves (a) administering a dose lower than 2400 mg/day for a time period, e.g., one week, two weeks, three weeks, four weeks, one month, six weeks, or two months, followed by (b) administering a dose of 2400 mg/day or 2403 mg/day.
• a time period e.g., one week, two weeks, three weeks, four weeks, one month, six weeks, or two months
• the pirfenidone is temporarily discontinued before step (a).
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) administering about 1600 mg/day or 1602 mg/day pirfenidone for about one week, or until the liver function biomarkers return to Grade 0 or Grade 1, and (b) administering the original full target dose for at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• the total daily dose is administered three times per day, with food.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) administering about 800 mg/day or 801 mg/day pirfenidone for about one week, or until the liver function biomarkers return to Grade 0 or Grade 1, (b) administering about 1600 mg/day or 1602 mg/day pirfenidone for about one week, and (c) administering the original full target dose for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• the total daily dose is administered three times per day, with food.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) discontinuing pirfenidone for about one week, or until the liver function biomarkers return to Grade 0 or Grade 1, (b) administering about 800 mg/day or 801 mg/day pirfenidone for about one week, (c) administering about 1600 mg/day or 1602 mg/day pirfenidone for about one week, and (d) administering the original full target dose for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• the total daily dose is administered three times per day, with food.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality at a permanently reduced dose, e.g. 800 or 801 mg/day, or 1600 or 1602 mg/day.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: administering about 1600 mg/day or 1602 mg/day pirfenidone for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) administering about 800 mg/day or 801 mg/day pirfenidone for about a week, or until biomarkers of liver function are within normal limits, and (b) administering about 1600 mg/day or 1602 mg/day pirfenidone to the patient for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) discontinuing pirfenidone for about one week, or until the liver function biomarkers return to Grade 0 or Grade 1, (b) administering about 800 mg/day or 801 mg/day pirfenidone for about a week, or until biomarkers of liver function are within normal limits, and (c) administering about 1600 mg/day or 1602 mg/day pirfenidone to the patient for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) discontinuing pirfenidone for about one week, or until the liver function biomarkers return to Grade 0 or Grade 1, and (b) administering about 1600 mg/day or 1602 mg/day pirfenidone to the patient for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• the invention also provides methods of administering pirfenidone to a patient at doses of 2400 mg/day or 2403 mg/day after identifying that the patient has exhibited a liver function Grade 1 abnormality after pirfenidone administration.
• the methods involve continuing the full target dose, e.g. of 2400 mg/day or 2403 mg/day, without temporarily discontinuing or reducing the dose.
• the patient's biomarkers of liver function may continue to be monitored.
• the method involves (a) administering a dose lower than 2400 mg/day for a time period, e.g., one week, two weeks, three weeks, four weeks, one month, six weeks, or two months, followed by (b) administering a dose of 2400 mg/day or 2403 mg/day.
• a time period e.g., one week, two weeks, three weeks, four weeks, one month, six weeks, or two months
• the pirfenidone is temporarily discontinued before step (a).
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) administering about 1600 mg/day or 1602 mg/day pirfenidone for a time period, optionally about one week, or until the liver function biomarkers return to Grade 0, and (b) administering the original full target dose for at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• the total daily dose is administered three times per day, with food.
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) administering about 800 mg/day or 801 mg/day pirfenidone for a time period, optionally about one week, or until the liver function biomarkers return to Grade 0, (b) administering about 1600 mg/day or 1602 mg/day pirfenidone for a time period, optionally about one week, and (c) administering the original full target dose for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• the total daily dose is administered three times per day, with food.
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) discontinuing pirfenidone for a time period, optionally about one week, or until the liver function biomarkers return to Grade 0, (b) administering about 800 mg/day or 801 mg/day pirfenidone for a time period, optionally about one week, (c) administering about 1600 mg/day or 1602 mg/day pirfenidone for a time period, optionally about one week, and (d) administering the original full target dose for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• the total daily dose is administered three times per day, with food.
• pirfenidone is administered at a permanently reduced dose, e.g. 800 or 801 mg/day, or 1600 or 1602 mg/day.
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: administering about 1600 mg/day or 1602 mg/day pirfenidone for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) administering about 800 mg/day or 801 mg/day pirfenidone for a time period, optionally about a week, or until biomarkers of liver function are within normal limits, and (b) administering about 1600 mg/day or 1602 mg/day pirfenidone to the patient for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) discontinuing pirfenidone for a time period, optionally about one week, or until the liver function biomarkers return to Grade 0, (b) administering about 800 mg/day or 801 mg/day pirfenidone for about a week, or until biomarkers of liver function are within normal limits, and (c) administering about 1600 mg/day or 1602 mg/day pirfenidone to the patient for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) discontinuing pirfenidone for a time period, optionally about one week, or until the liver function biomarkers return to Grade 0, and (b) administering about 1600 mg/day or 1602 mg/day pirfenidone to the patient for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years.
• any of the reduced doses of pirfenidone may be administered for a time period of 2 days, 3 days, 4 days, 5 days, 6 days, one week, about two weeks, or until the level of at least one biomarker of liver function has returned to within normal limits, or until all biomarkers or liver function has returned to within normal limits.
• the patient can have fibrotic lesional tissue.
• a patient is a patient who would benefit from pirfenidone administration.
• the patient is suffering from pulmonary fibrosis, idiopathic interstitial pneumonia, autoimmune lung diseases, benign prostate hypertrophy, coronary or myocardial infarction, atrial fibrillation, cerebral infarction, myocardiac fibrosis, musculoskeletal fibrosis, post-surgical adhesions, liver cirrhosis, renal fibrotic disease, fibrotic vascular disease, scleroderma, Hermansky-Pudlak syndrome, neurofibromatosis, Alzheimer's disease, diabetic retinopathy, and/or skin lesions.
• the patient is suffering from lymph node fibrosis associated with HIV. In one embodiment, the patient is suffering from pulmonary fibrosis, or idiopathic pulmonary fibrosis. In another embodiment, the patient is a person who would benefit from pirfenidone administration, optionally with the proviso that the patient is not suffering from idiopathic pulmonary fibrosis.
• the biomarker of liver function is alanine transaminase, aspartate transaminase, bilirubin, and/or alkaline phosphatase. Elevated gamma-glutamyl transferase has been observed in some patients receiving pirfenidone, without clinical liver impairment, and thus elevated gamma-glutamyl transferase alone is not necessarily a sign of liver impairment. In any of the embodiments described herein, biomarkers of liver function can exclude gamma-glutamyl transferase.
• the abnormal level of alanine transaminase, aspartate transaminase, or alkaline phosphatase is greater than about 2.5- fold increased compared to the upper limit of normal (ULN).
• the abnormal level of alanine transaminase, aspartate transaminase, or alkaline phosphatase is greater than about 2.5- to about 5-fold increased compared to the upper limit of normal (ULN), i.e. a "liver function Grade 2 abnormality".
• the abnormal level of bilirubin is greater than about 1.5- to about 3-fold increased compared to the upper limit of normal (ULN), i.e., a "liver function Grade 2 abnormality".
• the abnormal biomarkers of liver function e.g. elevated alanine transaminase and/or aspartate transaminase and/or elevated bilirubin, are accompanied by clinical signs of impaired liver function such as jaundice.
• the invention provides methods for administering a full therapeutically effective dose of pirfenidone to a patient that has exhibited abnormal levels of biomarkers of liver function after the patient has been treated with pirfenidone.
• liver function abnormalities can be indicative of drug-induced liver injury (hepatotoxicity)
• even patients that exhibit abnormal liver function may continue taking pirfenidone at the original full target dose, optionally after a short time period of discontinuing pirfenidone or taking the pirfenidone at reduced doses.
• This administration regimen has the advantage of maximizing the time on the full target dose of drug and therefore the potential for a beneficial therapeutic effect.
• the patient may be suffering from any disease for which pirfenidone therapy may be useful in ameliorating symptoms.
• a patient is a patient who would benefit from pirfenidone administration.
• diseases include, but are not limited to: chronic obstructive pulmonary disease (COPD), inflammatory pulmonary fibrosis (IPF), rheumatoid arthritis; rheumatoid spondylitis; osteoarthritis; gout, other arthritic conditions; sepsis; septic shock; endotoxic shock; gram-negative sepsis; toxic shock syndrome; myofacial pain syndrome (MPS); Shigellosis; asthma; adult respiratory distress syndrome; inflammatory bowel disease; Crohn's disease; psoriasis; eczema; ulcerative colitis; glomerular nephritis; scleroderma; chronic thyroiditis; Grave's disease; Ormond's disease; autoimmune gastritis; myasthenia grav
• the methods of the embodiments can be used to treat proliferative disorders (including both benign and malignant hyperplasias), including acute myelogenous leukemia, chronic myelogenous leukemia, Kaposi's sarcoma, metastatic melanoma, multiple myeloma, breast cancer, including metastatic breast carcinoma; colorectal carcinoma; malignant melanoma; gastric cancer; non-small cell lung cancer (NSCLC); bone metastases, and the like; pain disorders including neuromuscular pain, headache, cancer pain, dental pain, and arthritis pain; angiogenic disorders including solid tumor angiogenesis, ocular neovascularization, and infantile hemangioma; conditions associated with the cyclooxygenase and lipoxygenase signaling pathways, including conditions associated with prostaglandin endoperoxide synthase-2 (including edema, fever, analgesia, and pain); organ hypoxia; thrombin-induced platelet aggregation; proto-
• the methods of the invention optionally include identifying abnormal liver function in a patient receiving pirfenidone, and monitoring biomarkers of liver function in a patient receiving a reduced dose of pirfenidone.
• AST and/or ALT may be elevated, e.g. to a Grade 2 or Grade 3 level. In some embodiments, the elevation is to a Grade 1 level.
• AST and bilirubin may be elevated, or AST or ALP may be elevated, or AST and GGT may be elevated, or ALT and bilirubin may be elevated, or ALT and ALP may be elevated, or ALT and GGT may be elevated, or bilirubin and ALP may be elevated, or bilirubin and GGT may be elevated, e.g., to a Grade 1, Grade 2, or Grade 3 level.
• three biomarkers of liver function may be elevated, e.g., ALT and AST and bilirubin, or ALT and AST and ALP, to a Grade 1, Grade 2, or Grade 3 level.
• biomarkers of liver function can exclude gamma-glutamyl transferase.
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality after pirfenidone administration as follows: (a) administering at least about 1600 mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g. 22-24 mg/kg/day), or from 1400-1800 mg/day pirfenidone, or from 20 mg/kg/day to 26 mg/kg/day, for a time period. In some embodiments, step (a) is followed by (b) administering the original full target dose. In other embodiments, the original full target dose is continued without a temporary reduction or discontinuation of the dose.
• step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or until all biomarkers or liver function has returned to within normal limits.
• step (b) is carried out for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years, or more.
• the method includes measuring one or more biomarkers of liver function during step (a) and/or step (b).
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) administering at least about 800 mg/day or 801 mg/day pirfenidone, or about 11 mg/kg/day (e.g. 10-12 mg/kg/day), or from 600-1000 mg/day, or from 700-900 mg/day, or from 8 mg/kg/day to 15 mg/kg/day, for a time period, (b) administering at least about 1600 mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g.
• the time period of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• the time period of step (b) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• step (c) is carried out for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years, or more.
• the method includes measuring one or more biomarkers of liver function during step (a) and/or step (b) and/or step (c).
• pirfenidone is administered to a patient exhibiting a liver function Grade 2 abnormality as follows: (a) discontinuing pirfenidone for a time period, (b) administering at least about 800 mg/day or 801 mg/day pirfenidone, or about 11 mg/kg/day (e.g. 10-12 mg/kg/day), or from 600-1000 mg/day, or from 700-900 mg/day, or from 8 mg/kg/day to 15 mg/kg/day, for a time period, (c) administering at least about 1600 mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g.
• the time period of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• the time period of step (b) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• the time period of step (c) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• step (d) is carried out for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years, or more.
• the method includes measuring one or more biomarkers of liver function during step (a) and/or step (b) and/or step (c) and/or step (d).
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) administering at least about 1600 mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g. 22-24 mg/kg/day), or from 1400-1800 mg/day pirfenidone, or from 20 mg/kg/day to 26 mg/kg/day, for a time period, and (b) administering the original full target dose.
• step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or until all biomarkers or liver function has returned to within normal limits.
• step (b) is carried out for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years, or more.
• the method includes measuring one or more biomarkers of liver function during step (a) and/or step (b).
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) administering at least about 800 mg/day or 801 mg/day pirfenidone, or about 11 mg/kg/day (e.g. 10-12 mg/kg/day), or from 600-1000 mg/day, or from 700-900 mg/day, or from 8 mg/kg/day to 15 mg/kg/day, for a time period, (b) administering at least about 1600 mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g.
• the time period of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• the time period of step (b) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• step (c) is carried out for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years, or more.
• the method includes measuring one or more biomarkers of liver function during step (a) and/or step (b) and/or step (c).
• pirfenidone is administered to a patient exhibiting a liver function Grade 1 abnormality as follows: (a) discontinuing pirfenidone for a time period, (b) administering at least about 800 mg/day or 801 mg/day pirfenidone, or about 11 mg/kg/day (e.g. 10-12 mg/kg/day), or from 600-1000 mg/day, or from 700-900 mg/day, or from 8 mg/kg/day to 15 mg/kg/day, for a time period, (c) administering at least about 1600 mg/day or 1602 mg/day pirfenidone, or about 23 mg/kg/day (e.g.
• the time period of step (a) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• the time period of step (b) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• the time period of step (c) is 2 days, 3 days, 4 days, 5 days, 6 days, about one week, about two weeks, about three weeks, about four weeks, about 1 month, or until the level of at least one biomarker of liver function has returned to within normal limits, or to Grade 1, or until all biomarkers or liver function has returned to within normal limits, or to Grade 1.
• step (d) is carried out for a time period of at least one week, two weeks, three weeks, four weeks or a month, two months, or three months, or one year, or two years, or three years, or four years, or five years, or seven years, or ten years, or more.
• the method includes measuring one or more biomarkers of liver function during step (a) and/or step (b) and/or step (c) and/or step (d).
• Pirfenidone can be provided in tablet or capsule forms or any other oral dosage form, and typically is formulated for oral administration. Exemplary capsule formulations are described in WO 2007/038315 (Int'l Appl. No. PCT/US2006/037057 ).
• Pirfenidone therapy can be associated with adverse effects including photosensitivity rash, anorexia (decreased appetite), stomach discomfort, nausea, heartburn, drowsiness (somnolence), fatigue, upper respiratory tract infection, fever, positive urinary occult blood, elevation of C-reactive protein (CRP), decreased weight, headache, constipation, and malaise.
• Abnormal liver function also can occur as an adverse effect (AE) in patients receiving pirfenidone.
• AE adverse effect
• the baseline liver function of the patient Prior to receiving pirfenidone, can be, and typically is, normal. Liver function can be assessed by various means known in the art, such as blood chemistry tests measuring biomarkers of liver function.
• biomarkers of liver function include, but are not limited to, alanine transaminase (ALT), aspartate transaminase (AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT).
• ALT alanine transaminase
• AST aspartate transaminase
• ALP alkaline phosphatase
• GTT gamma-glutamyl transferase
• ALT Alanine transaminase
• SGPT serum glutamic pyruvate transaminase
• ALAT alanine aminotransferase
• AST Aspartate transaminase
• SGOT serum glutamic oxaloacetic transaminase
• ASAT aspartate aminotransferase
• AST can increase in response to liver damage. Elevated AST also can result from damage to other sources, including red blood cells, cardiac muscle, skeletal muscle, kidney tissue, and brain tissue. The ratio of AST to ALT can be used as a biomarker of liver damage.
• Bilirubin is a catabolite of heme that is cleared from the body by the liver. Conjugation of bilirubin to glucuronic acid by hepatocytes produces direct bilirubin, a watersoluble product that is readily cleared from the body. Indirect bilirubin is unconjugated, and the sum of direct and indirect bilirubin constitutes total bilirubin. Elevated total bilirubin can be indicative of liver impairment.
• Alkaline phosphatase hydrolyzes phosphate groups from various molecules and is present in the cells lining the biliary ducts of the liver.
• ALP levels in plasma can rise in response to liver damage, and are higher in growing children and elderly patients with Paget's disease.
• elevated ALP levels usually reflect biliary tree disease.
• CTC Common Toxicity Criteria
• CTCE Common Terminology Criteria for Adverse Events v3.0
• the ULN for various indicators of liver function depends on the assay used, the patient population, and each laboratory's normal range of values for the specified biomarker, but can readily be determined by the skilled practitioner. Exemplary values for normal ranges for a healthy adult population are set forth in Table 2 below. See Cecil Textbook of Medicine, pp. 2317-2341, W.B. Saunders & Co. (1985 ). Table 2 ALT 8-20 U/L AST 8-20 U/L Bilirubin 0.2-1.0 mg/dL 3.4-17.1 ⁇ mol/L ALP 20-70 U/L GGT Men: 9-50 U/L Women: 8-40 U/L
• Grade 0 levels are characterized by biomarker levels within normal limits (WNL).
• Normal refers to Grade 0 adverse effects.
• Abnormal liver function, as used herein, refers to Grade 1 and above adverse effects.
• Grade 1 liver function abnormalities include elevations in ALT, AST, ALP, or GGT greater than the ULN and less than or equal to 2.5-times the ULN.
• Grade 1 liver function abnormalities also include elevations of bilirubin levels greater than the ULN and less than or equal to 1.5-times the ULN.
• Grade 2 liver function abnormalities include elevations in alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), or gamma-glutamyl transferase (GGT) greater than 2.5-times and less than or equal to 5-times the upper limit of normal (ULN).
• Grade 2 liver function abnormalities also include elevations of bilirubin levels greater than 1.5-times and less than or equal to 3-times the ULN.
• Grade 3 liver function abnormalities include elevations in ALT, AST, ALP, or GGT greater than 5-times and less than or equal to 20-times the ULN.
• Grade 3 liver function abnormalities also include elevations of bilirubin levels greater than 3-times and less than or equal to 10-times the ULN.
• Grade 4 liver function abnormalities include elevations in ALT, AST, ALP, or GGT greater than 20-times the ULN. Grade 4 liver function abnormalities also include elevations of bilirubin levels greater than 10 the ULN.
• the present disclosure provides methods for treating a patient having idiopathic pulmonary fibrosis and receiving a full target dose of pirfenidone, wherein the full target dose is 2400 or 2403 mg pirfenidone per day.
• a patient with abnormal liver function is administered a second dose of pirfenidone, wherein the second dose is 1600 or 1602 mg pirfenidone per day until liver function is within normal limits, followed by administering the patient the full target dose of 2400 or 2403 mg pirfenidone per day.
• the present disclosure also provides methods for treatment of patients that exhibit Grade 1 abnormality in one or more biomarkers of liver function after pirfenidone administration.
• the method includes administering to the patient pirfenidone at doses of 2400 mg/day or 2403 mg/day or administering to the patient pirfenidone at doses of 1600 mg/day or 1602 mg/day.
• the patient may be receiving pirfenidone for treatment of idiopathic pulmonary fibrosis.
• the patient may be suffering from a condition for which pirfenidone administration may be beneficial.
• patients may receive reduced doses or discontinue treatment for a time period, and then resume administration of pirfenidone.
• Ranges may be expressed herein as from “about” or “approximately” one particular value and/or to “about” or “approximately” another particular value. When such a range is expressed, another embodiment includes from the one particular value and/or to the other particular value. Similarly, when values are expressed as approximations, by use of the antecedent "about,” it will be understood that the particular value forms another embodiment.
• the invention provides pirfenidone as a medicament wherein the administration pattern of the medicament comprises administering according to any of the treatment methods described herein.
• the invention provides pirfenidone for use in treating a patient with idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration according to any of the treatment regimes as described above with respect to the methods of the invention for administering pirfenidone to a patient for treating idiopathic pulmonary fibrosis or to a patient who would benefit from pirfenidone administration.
• Pirfenidone is packaged and presented for use in a treating a patient with idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration according to such treatment regimes. Pirfenidone is administered to the patient in accordance with the treatment regimes as described above.
• the patient is one who has exhibited abnormal biomarkers of liver function after pirfenidone administration as is described above with respect to the methods of the invention for administering pirfenidone to a patient for treating idiopathic pulmonary fibrosis or to a patient who would benefit from pirfenidone administration.
• the invention includes pirfenidone for use in treating a patient with idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration, said patient having exhibited a Grade 1 or Grade 2 abnormality in one or more biomarkers of liver function after pirfenidone administration, wherein said patient is administered pirfenidone at doses of 2400 mg/day or 2403 mg/day.
• said patient is administered pirfenidone at doses lower than 2400 mg/day for a time period.
• the invention further includes pirfenidone for use in treating a patient with idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration, said patient having exhibited a Grade 1 or Grade 2 abnormality in one or more biomarkers of liver function after pirfenidone administration, wherein said patient is administered pirfenidone at doses of 1600 mg/day or 1602 mg/day.
• said patient is administered pirfenidone at doses lower than 1600 mg/day or 1602 mg/day for a time period.
• the invention provides the use of pirfenidone in the manufacture of a medicament for treating a patient with idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration according to any of the treatment regimes as described above with respect to any of the methods.
• the medicaments manufactured according to this aspect of the invention are for use in treating a patient with idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration in accordance with such treatment regimes.
• the medicament so manufactured is administered to the patient in accordance with the treatment regimes as described above.
• the patient is one who has exhibited abnormal biomarkers of liver function after pirfenidone administration as is described above with respect to the methods of the invention for administering pirfenidone to a patient for treating idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration.
• the invention includes the use of pirfenidone in the manufacture of a medicament for treating a patient with idiopathic pulmonary fibrosis or a patient who would benefit from pirfenidone administration, said patient having exhibited a Grade 1 or Grade 2 abnormality in one or more biomarkers of liver function after pirfenidone administration, wherein said patient is administered pirfenidone at doses of 2400 mg/day or 2403 mg/day.
• said patient is administered pirfenidone at doses lower than 2400 mg/day for a time period.
• the preferences expressed with respect to the preferred embodiments of the aspect of the invention relating to a method for administering pirfenidone to treat a patient with idiopathic pulmonary fibrosis apply in the same way.
• the examples relate to pirfenidone for use in treating a patient with idiopathic pulmonary fibrosis, and to use of pirfenidone in the manufacture of a medicament for treating a patient with idiopathic pulmonary fibrosis, as well as to a method for administering pirfenidone to a patient for treating idiopathic pulmonary fibrosis.
• Patients begin pirfenidone treatment by receiving escalating doses of pirfenidone over a period of 15 days until the full maintenance dose is reached. Specifically, from days 1 to 7, patients are administered one capsule of 267 mg pirfenidone three times per day. During days 8 to 14, patients receive two capsules of 267 mg pirfenidone three times per day. From day 15 onward, patients are treated with three capsules of 267 mg pirfenidone three times per day. Pirfenidone is administered orally, and each dose should be taken with food. If the patient is unable to eat, then the pirfenidone dose should be taken with milk or juice (excluding grapefruit juice).
• Pirfenidone is known to cause photosensitivity reactions; therefore, throughout the treatment period, patients should use sun block that protects against at least UV-A with a sun protective factor (SPF) of 50. In addition, patients should wear appropriate clothing to minimize sun exposure, and if possible, avoid other medications known to cause photosensitivity reactions.
• SPF sun protective factor
• pirfenidone is administered orally to patients three times per day to provide a daily dose of 2403 mg pirfenidone.
• Each of the three doses of 801 mg pirfenidone includes three capsules of 267 mg pirfenidone each.
• the contents of the pirfenidone 267 mg capsules are pirfenidone (82.15%); croscarmellose sodium (8.15%); microcrystalline cellulose (7.39%); povidine, USP, EP (1.85%); and magnesium stearate (0.46%).
• Patients are treated with pirfenidone for up to 72 weeks. Some patients are treated longer than 72 weeks. At weeks 2, 4, 6, 12, and every 12 weeks ( ⁇ 2 weeks) thereafter during the treatment period, with the exception of week 72 and the treatment completion visit, patients are examined and histories are collected as detailed in the steps below.
• Patient history is collected to include review of adverse effects (AEs) and severe adverse effects (SAEs), use of concomitant medications, use of oxygen, hospitalizations, IPF exacerbations or acute respiratory decompensation, and dosing.
• AEs adverse effects
• SAEs severe adverse effects
• Pulmonary function is assessed by spirometry before and after administration of bronchodilators. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) are measured.
• FVC Forced vital capacity
• FEV1 forced expiratory volume in 1 second
• Clinical laboratory tests are performed, including hematology, serum chemistries, pregnancy tests for women of childbearing capacity, and urinalysis with microscopic examination.
• UCSD SOBQ University of California at San Diego Shortness of Breath Questionnaire
• SGRQ St. George's Hospital Respiratory Questionnaire
• WHO QOL World Health Organization Quality of Life
• ECG electrocardiogram
• PFT pulmonary function test
• PK pharmacokinetic
• ALT alanine transaminase
• AST aspartate transaminase
• bilirubin alanine transaminase
• pirfenidone Patients are treated with pirfenidone in accordance with Example 1. During the course of pirfenidone treatment, patients exhibiting abnormal liver function test results are candidates for dose modification. As described in Example 1, serum chemistry tests are performed at scheduled intervals during the treatment period to monitor various parameters, including biomarkers of liver function such as alanine transaminase (ALT), aspartate transaminase (AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT).
• ALT alanine transaminase
• AST aspartate transaminase
• bilirubin bilirubin
• ALP alkaline phosphatase
• GTT gamma-glutamyl transferase
• the pirfenidone dose is reduced to one capsule of 267 mg pirfenidone three times per day. While receiving the reduced pirfenidone dose, the patient undergoes additional monitoring of AST, ALT and bilirubin. The reduced pirfenidone dose is continued at least until AST, ALT and bilirubin are all Grade 1 or within normal limits (Grade 0). The reduced pirfenidone dose can be administered for a period of time after AST, ALT and bilirubin have reached Grade 1 or Grade 0.
• the pirfenidone dose can be re-escalated in a manner consistent with the initial dose escalation, up to a dose of 6 capsules per day.
• the pirfenidone dose also can be re-escalated in a manner consistent with the initial dose escalation, up to the maximum of 9 capsules per day.
• Serum chemistry tests are optionally performed at scheduled intervals during the escalation period, e.g. weekly or every 2 weeks, or every 3 weeks, or every month to monitor various parameters, including biomarkers of liver function such as alanine transaminase (ALT), aspartate transaminase (AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT).
• ALT alanine transaminase
• AST aspartate transaminase
• bilirubin bilirubin
• ALP alkaline phosphatase
• GTT gamma-glutamyl transferase
• pirfenidone Patients are treated with pirfenidone in accordance with Example 1. During the course of pirfenidone treatment, patients exhibiting abnormal liver function test results are candidates for dose modification. As described in Example 1, serum chemistry tests are performed at scheduled intervals during the treatment period to monitor various parameters, including biomarkers of liver function such as alanine transaminase (ALT), aspartate transaminase (AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT).
• ALT alanine transaminase
• AST aspartate transaminase
• bilirubin bilirubin
• ALP alkaline phosphatase
• GTT gamma-glutamyl transferase
• the pirfenidone dose is discontinued. Following discontinuation of the pirfenidone dose, the patient undergoes additional monitoring of AST, ALT and bilirubin. Pirfenidone dosing is discontinued at least until AST, ALT and bilirubin are all Grade 1 or within normal limits (Grade 0). The pirfenidone dose can be discontinued for a period of time after AST, ALT and bilirubin have reached Grade 1 or Grade 0.
• the pirfenidone dose is re-escalated in a manner consistent with the initial dose escalation, up to a dose of 6 or 9 capsules per day, i.e. 1602 mg/day or 2403 mg/day.
• the pirfenidone dose is re-instituted at a dose of 6 capsules per day, i.e. 1602 mg/day, and re-escalated after 1 week to the maximum of 9 capsules per day.
• Serum chemistry tests are optionally performed at scheduled intervals during the escalation period, e.g. weekly, or every 2 weeks, or every month, to monitor various parameters, including biomarkers of liver function such as alanine transaminase (ALT), aspartate transaminase (AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT).
• ALT alanine transaminase
• AST aspartate transaminase
• bilirubin bilirubin
• ALP alkaline phosphatase
• GTT gamma-glutamyl transferase
• pirfenidone Patients are treated with pirfenidone in accordance with Example 1. During the course of pirfenidone treatment, patients exhibiting abnormal liver function test results are candidates for dose modification. As described in Example 1, serum chemistry tests are performed at scheduled intervals during the treatment period to monitor various parameters, including biomarkers of liver function such as alanine transaminase (ALT), aspartate transaminase (AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT).
• ALT alanine transaminase
• AST aspartate transaminase
• bilirubin bilirubin
• ALP alkaline phosphatase
• GTT gamma-glutamyl transferase
• the pirfenidone dose is reduced to two capsules of 267 mg pirfenidone three times per day, i.e. 1602 mg/day. While receiving the reduced pirfenidone dose, the patient undergoes additional monitoring of AST, ALT and bilirubin. The reduced pirfenidone dose is continued at least until AST, ALT and bilirubin are all Grade 1 or within normal limits (Grade 0). The reduced pirfenidone dose can be administered for a period of time after AST, ALT and bilirubin have reached Grade 1 or Grade 0.
• the pirfenidone dose can be re-escalated to the maximum of 9 capsules per day, i.e. 2403 mg.
• ALT alanine transaminase
• AST aspartate transaminase
• ALP alkaline phosphate
• GTT gamma-glutamyl transferase
• a patient exhibited a Grade 1 or Grade 2 increase in any one of AST, ALT, or bilirubin, the pirfenidone dose was not reduced for some patients.
• the patient continued to receive the full target dose of 2403 mg/day. While receiving the full target dose, the patient was monitored for AST, ALT, and bilirubin levels.
• study drug dose was reduced to 1602 mg/day and then increased to 2403 mg/day for remainder of study participation, and ALT returned to Grade 0.
• the third patient had study drug dose reduced to 801 mg/day, ultimately completing study at 1602 mg/day, at which time ALT returned to Grade 0.
• the dose for this patient was initially decreased to 1602 mg/day, then discontinued, and then resumed at 1602 mg/day.
• treatment was permanently discontinued because a Grade 2 elevation of AST coincided with a Grade 3 ALT elevation in liver function tests.

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